White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatars

Facility

$18,794.85

Service Code	HCPCS 28307
Hospital Charge Code	9900510
Hospital Revenue Code	360
Min. Negotiated Rate	$2,398.52
Max. Negotiated Rate	$15,408.22
Rate for Payer: Amerigroup CHIP/Medicaid	$2,398.52
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Amerigroup Medicare	$7,289.28
Rate for Payer: BCBS of TX Blue Advantage	$9,989.86
Rate for Payer: BCBS of TX Blue Essentials	$11,963.90
Rate for Payer: BCBS of TX Medicare	$7,289.28
Rate for Payer: BCBS of TX PPO	$15,074.51
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cash Price	$12,780.50
Rate for Payer: Cigna Commercial	$15,408.22
Rate for Payer: Cigna Medicaid	$13,532.29
Rate for Payer: Cigna Medicare	$7,289.28
Rate for Payer: Employer Direct Commercial	$7,289.28
Rate for Payer: Humana Medicare/TRICARE	$7,289.28
Rate for Payer: Molina CHIP/Medicaid	$13,532.29
Rate for Payer: Molina Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Molina Medicare	$7,289.28
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$13,532.29
Rate for Payer: Scott and White EPO/PPO	$12,104.03
Rate for Payer: Scott and White Medicare	$7,289.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,532.29
Rate for Payer: Superior Health Plan EPO	$7,289.28
Rate for Payer: Superior Health Plan Medicare	$7,289.28
Rate for Payer: Universal American Dual Medicare/Medicaid	$7,289.28
Rate for Payer: Universal American Medicare	$7,289.28
Rate for Payer: Wellcare Medicare	$7,289.28
Rate for Payer: Wellmed Medicare	$7,289.28

Osteotomy, with or without lengthening, shortening or angular correction, metatarsal other than fir

Facility

$10,000.00

Service Code	CPT 28308
Hospital Charge Code	36028308
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Osteotomy, with or without lengthening, shortening or angular correction, metatarsal other than fir

Facility

$7,076.00

Service Code	HCPCS 28308
Hospital Charge Code	9900511
Hospital Revenue Code	360
Rate for Payer: Cash Price	$4,811.68

Osteotomy, with or without lengthening, shortening or angular correction, metatarsal other than fir

Facility

$7,076.00

Service Code	HCPCS 28308
Hospital Charge Code	9900511
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cash Price	$4,811.68
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$5,094.72
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$5,094.72
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,094.72
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,094.72
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Ostomy bag replacement only, each

Facility

$112.00

Service Code	HCPCS A4363
Hospital Charge Code	994102
Hospital Revenue Code	272
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$80.64
Rate for Payer: Amerigroup CHIP/Medicaid	$10.08
Rate for Payer: BCBS of TX Blue Advantage	$3.99
Rate for Payer: BCBS of TX Blue Essentials	$4.79
Rate for Payer: BCBS of TX PPO	$5.31
Rate for Payer: Cash Price	$76.16
Rate for Payer: Cash Price	$76.16
Rate for Payer: Cigna Medicaid	$80.64
Rate for Payer: Molina CHIP/Medicaid	$80.64
Rate for Payer: Multiplan Auto	$72.80
Rate for Payer: Multiplan Commercial	$72.80
Rate for Payer: Multiplan Workers Comp	$72.80
Rate for Payer: Parkland Medicaid	$80.64
Rate for Payer: Scott and White EPO/PPO	$4.04
Rate for Payer: Superior Health Plan CHIP/Medicaid	$80.64
Rate for Payer: Superior Health Plan EPO	$15.23

Ostomy bag replacement only, each

Facility

$112.00

Service Code	HCPCS A4363
Hospital Charge Code	994102
Hospital Revenue Code	272
Rate for Payer: Cash Price	$76.16

OST PASTE STMA -- DHF

Facility

$17.36

Hospital Charge Code	80331457
Hospital Revenue Code	272
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$12.50
Rate for Payer: Amerigroup CHIP/Medicaid	$1.56
Rate for Payer: BCBS of TX Blue Advantage	$5.21
Rate for Payer: BCBS of TX Blue Essentials	$6.25
Rate for Payer: BCBS of TX PPO	$6.94
Rate for Payer: Cash Price	$11.80
Rate for Payer: Cigna Medicaid	$12.50
Rate for Payer: Molina CHIP/Medicaid	$12.50
Rate for Payer: Multiplan Auto	$11.28
Rate for Payer: Multiplan Commercial	$11.28
Rate for Payer: Multiplan Workers Comp	$11.28
Rate for Payer: Parkland Medicaid	$12.50
Rate for Payer: Scott and White EPO/PPO	$8.68
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12.50
Rate for Payer: Superior Health Plan EPO	$2.36

OST PASTE STMA -- DHF

Facility

$17.36

Hospital Charge Code	80331457
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.80

OST SKIN BOND -- DHF

Facility

$367.82

Hospital Charge Code	80332000
Hospital Revenue Code	272
Rate for Payer: Cash Price	$250.12

OST SKIN BOND -- DHF

Facility

$367.82

Hospital Charge Code	80332000
Hospital Revenue Code	272
Min. Negotiated Rate	$33.10
Max. Negotiated Rate	$264.83
Rate for Payer: Amerigroup CHIP/Medicaid	$33.10
Rate for Payer: BCBS of TX Blue Advantage	$110.35
Rate for Payer: BCBS of TX Blue Essentials	$132.42
Rate for Payer: BCBS of TX PPO	$147.13
Rate for Payer: Cash Price	$250.12
Rate for Payer: Cigna Medicaid	$264.83
Rate for Payer: Molina CHIP/Medicaid	$264.83
Rate for Payer: Multiplan Auto	$239.08
Rate for Payer: Multiplan Commercial	$239.08
Rate for Payer: Multiplan Workers Comp	$239.08
Rate for Payer: Parkland Medicaid	$264.83
Rate for Payer: Scott and White EPO/PPO	$183.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$264.83
Rate for Payer: Superior Health Plan EPO	$50.02

OST SKIN PROTEC -- DHF

Facility

$16.54

Hospital Charge Code	80332257
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.25

OST SKIN PROTEC -- DHF

Facility

$16.54

Hospital Charge Code	80332257
Hospital Revenue Code	272
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$11.91
Rate for Payer: Amerigroup CHIP/Medicaid	$1.49
Rate for Payer: BCBS of TX Blue Advantage	$4.96
Rate for Payer: BCBS of TX Blue Essentials	$5.95
Rate for Payer: BCBS of TX PPO	$6.62
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna Medicaid	$11.91
Rate for Payer: Molina CHIP/Medicaid	$11.91
Rate for Payer: Multiplan Auto	$10.75
Rate for Payer: Multiplan Commercial	$10.75
Rate for Payer: Multiplan Workers Comp	$10.75
Rate for Payer: Parkland Medicaid	$11.91
Rate for Payer: Scott and White EPO/PPO	$8.27
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.91
Rate for Payer: Superior Health Plan EPO	$2.25

OTAH OTA Biofeedback Assistant Units BCE

Facility

$448.00

Service Code	HCPCS 90901
Hospital Charge Code	8995055
Hospital Revenue Code	430
Min. Negotiated Rate	$23.45
Max. Negotiated Rate	$322.56
Rate for Payer: Amerigroup CHIP/Medicaid	$40.32
Rate for Payer: BCBS of TX Blue Advantage	$134.40
Rate for Payer: BCBS of TX Blue Essentials	$161.28
Rate for Payer: BCBS of TX PPO	$179.20
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cash Price	$304.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$322.56
Rate for Payer: Molina CHIP/Medicaid	$322.56
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Parkland Medicaid	$322.56
Rate for Payer: Scott and White EPO/PPO	$23.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$322.56
Rate for Payer: Superior Health Plan EPO	$60.93

OTAH OTA Biofeedback Assistant Units BCE

Facility

$448.00

Service Code	HCPCS 90901
Hospital Charge Code	8995055
Hospital Revenue Code	430
Rate for Payer: Cash Price	$304.64

OTAH OTA Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	8997088
Hospital Revenue Code	430
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$9.99
Rate for Payer: BCBS of TX Blue Advantage	$33.30
Rate for Payer: BCBS of TX Blue Essentials	$39.96
Rate for Payer: BCBS of TX PPO	$44.40
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cash Price	$75.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$79.92
Rate for Payer: Molina CHIP/Medicaid	$79.92
Rate for Payer: Multiplan Auto	$72.15
Rate for Payer: Multiplan Commercial	$72.15
Rate for Payer: Multiplan Workers Comp	$72.15
Rate for Payer: Parkland Medicaid	$79.92
Rate for Payer: Scott and White EPO/PPO	$23.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$79.92
Rate for Payer: Superior Health Plan EPO	$15.10

OTAH OTA Iontophoresis Assistant Units BCE

Facility

$111.00

Service Code	HCPCS 97033
Hospital Charge Code	8997088
Hospital Revenue Code	430
Rate for Payer: Cash Price	$75.48

OTAH OTA Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	8997093
Hospital Revenue Code	430
Rate for Payer: Cash Price	$92.48

OTAH OTA Manual Therapy Assistant Units BCE

Facility

$136.00

Service Code	HCPCS 97140
Hospital Charge Code	8997093
Hospital Revenue Code	430
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$12.24
Rate for Payer: BCBS of TX Blue Advantage	$40.80
Rate for Payer: BCBS of TX Blue Essentials	$48.96
Rate for Payer: BCBS of TX PPO	$54.40
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cash Price	$92.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$97.92
Rate for Payer: Molina CHIP/Medicaid	$97.92
Rate for Payer: Multiplan Auto	$88.40
Rate for Payer: Multiplan Commercial	$88.40
Rate for Payer: Multiplan Workers Comp	$88.40
Rate for Payer: Parkland Medicaid	$97.92
Rate for Payer: Scott and White EPO/PPO	$33.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$97.92
Rate for Payer: Superior Health Plan EPO	$18.50

OTAH OTA Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	8997092
Hospital Revenue Code	430
Rate for Payer: Cash Price	$87.72

OTAH OTA Neuromuscular Reeducation Assistant Units BCE

Facility

$129.00

Service Code	HCPCS 97112
Hospital Charge Code	8997092
Hospital Revenue Code	430
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$11.61
Rate for Payer: BCBS of TX Blue Advantage	$38.70
Rate for Payer: BCBS of TX Blue Essentials	$46.44
Rate for Payer: BCBS of TX PPO	$51.60
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cash Price	$87.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$92.88
Rate for Payer: Molina CHIP/Medicaid	$92.88
Rate for Payer: Multiplan Auto	$83.85
Rate for Payer: Multiplan Commercial	$83.85
Rate for Payer: Multiplan Workers Comp	$83.85
Rate for Payer: Parkland Medicaid	$92.88
Rate for Payer: Scott and White EPO/PPO	$41.66
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.88
Rate for Payer: Superior Health Plan EPO	$17.54

OTAH OTA Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	8997097
Hospital Revenue Code	430
Rate for Payer: Cash Price	$119.00

OTAH OTA Orthotic Management, Train Assistant Units BCE

Facility

$175.00

Service Code	HCPCS 97760
Hospital Charge Code	8997097
Hospital Revenue Code	430
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$15.75
Rate for Payer: BCBS of TX Blue Advantage	$52.50
Rate for Payer: BCBS of TX Blue Essentials	$63.00
Rate for Payer: BCBS of TX PPO	$70.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cash Price	$119.00
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$126.00
Rate for Payer: Molina CHIP/Medicaid	$126.00
Rate for Payer: Multiplan Auto	$113.75
Rate for Payer: Multiplan Commercial	$113.75
Rate for Payer: Multiplan Workers Comp	$113.75
Rate for Payer: Parkland Medicaid	$126.00
Rate for Payer: Scott and White EPO/PPO	$58.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$126.00
Rate for Payer: Superior Health Plan EPO	$23.80

OTAH OTA Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	8995062
Hospital Revenue Code	430
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$200.00
Rate for Payer: Amerigroup CHIP/Medicaid	$18.18
Rate for Payer: BCBS of TX Blue Advantage	$60.60
Rate for Payer: BCBS of TX Blue Essentials	$72.72
Rate for Payer: BCBS of TX PPO	$80.80
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cash Price	$137.36
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Cigna Medicaid	$145.44
Rate for Payer: Molina CHIP/Medicaid	$145.44
Rate for Payer: Multiplan Auto	$131.30
Rate for Payer: Multiplan Commercial	$131.30
Rate for Payer: Multiplan Workers Comp	$131.30
Rate for Payer: Parkland Medicaid	$145.44
Rate for Payer: Scott and White EPO/PPO	$64.74
Rate for Payer: Superior Health Plan CHIP/Medicaid	$145.44
Rate for Payer: Superior Health Plan EPO	$27.47

OTAH OTA Orthotic/Prosthetic Manage,Train Assistant Units BCE

Facility

$202.00

Service Code	HCPCS 97763
Hospital Charge Code	8995062
Hospital Revenue Code	430
Rate for Payer: Cash Price	$137.36

OTAH OTA Self Care, Home Management Assistant Units BCE

Facility

$125.00

Service Code	HCPCS 97535
Hospital Charge Code	8997095
Hospital Revenue Code	430
Rate for Payer: Cash Price	$85.00

Know your out-of-pocket cost for care.

All Charges